Experimental/Investigational

Experimental-Investigational

Policy ID: Z-67-069

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: March 17, 2021

Revision Effective Date: April 01, 2021

Last Reviewed: March 17, 2021

Description

Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service, or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.

This policy addresses services considered to be experimental/investigational and therefore, non-covered services.

Criteria

Services meeting ANY of the following criteria are considered experimental/investigational:

The intervention does not have Food and Drug Administration (FDA) approval to be marketed for the specific relevant indication(s); or
Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
The intervention does not improve health outcomes; or
The intervention is not proven to be applicable outside the research setting.

Procedure codes identified within this policy are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.

Procedure Codes

0014M	0015M	0017M	0100T	0174T	0175T	0198T
0200T	0201T	0202T	0207T	0219T	0220T	0221T
0222T	0263T	0264T	0265T	0266T	0267T	0268T
0269T	0270T	0271T	0272T	0273T	0278T	0329T
0330T	0333T	0335T	0338T	0339T	0342T	0356T
0358T	0378T	0379T	0408T	0409T	0410T	0411T
0412T	0413T	0414T	0415T	0416T	0417T	0418T
0421T	0422T	0423T	0437T	0439T	0440T	0441T
0442T	0443T	0444T	0445T	0451T	0452T	0453T
0454T	0455T	0456T	0457T	0458T	0459T	0460T
0461T	0462T	0463T	0465T	0469T	0470T	0471T
0472T	0473T	0475T	0476T	0477T	0478T	0479T
0480T	0484T	0485T	0486T	0487T	0488T	0489T
0490T	0491T	0492T	0493T	0497T	0498T	0499T
0505T	0506T	0507T	0508T	0512T	0513T	0515T
0516T	0517T	0518T	0519T	0520T	0521T	0522T
0523T	0525T	0526T	0527T	0528T	0529T	0530T
0531T	0532T	0533T	0534T	0535T	0536T	0541T
0542T	0543T	0544T	0545T	0546T	0547T	0548T
0549T	0550T	0551T	0552T	0553T	0554T	0555T
0556T	0557T	0558T	0559T	0560T	0561T	0562T
0563T	0564T	0565T	0566T	0567T	0568T	0569T
0570T	0571T	0572T	0573T	0574T	0575T	0576T
0577T	0578T	0579T	0580T	0581T	0582T	0583T
0594T	0596T	0597T	0598T	0599T	0600T	0601T
0602T	0603T	0604T	0605T	0606T	0607T	0608T
0609T	0610T	0611T	0612T	0613T	0615T	0616T
0617T	0618T	0619T	0620T	0621T	0622T	0623T
0624T	0625T	0626T	0627T	0628T	0629T	0630T
0631T	0632T	0633T	0634T	0635T	0636T	0637T
0638T	0639T	0174U	0176U	0178U	0234U	0247U
30468	32994	33440	57465	64454	64625	90587
90689	91022	92145	92229	93895	96931	96932
96933	96934	96935	96936	A4563	K1001	K1006
K1009	K1016	K1017	K1018	K1019	L2006	L8608
L8701	L8702	Q0035	S9025

Outpatient HCPCS (C Codes)

C1734	C1748	C1824	C1825	C1839	C2596	C9250
C9758	C9759	C9760	C9762	C9763	C9764	C9765
C9766	C9767	C9771	C9772	C9773	C9774	C9775

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 new code update

Internal Medical Policy Committee 7-22-2020 Coding update for July HCPCS

Procedure Codes:
- Removed: 0124U; 0125U; 0126U; 0127U; 0128U
- Added: 0174U; 0176U; 0178U; 0596T; 0597T; 0598T; 0599T; 0600T; 0601T; 0602T; 0603T; 0604T; 0605T; 0606T; 0607T; 0608T; 0609T; 0610T; 0611T; 0612T; 0613T; 0615T; 0616T; 0617T; 0618T; 0619T.
Outpatient HCPCS (Codes)
- Added: C1748; C9759; C9760; C9762; C9763; C9764; C9765; C9766; C9767

Internal Medical Policy Committee 9-21-2020 Coding update:

Procedure codes:
- Adding: 0015M; K1006; K1009; K1010; K1011; and K1012

Internal Medical Policy Committee 11-19-20 Coding update:

Procedure codes:
- Removed 31647; 31648; 31649; 31651; 0424T; 0425T; 0426T; 0427T; 0428T; 0429T; 0430T; 0431T; 0432T; 0433T; 0434T; 0435T; 0436T and C1982

Internal Medical Policy Committee 11-19-21 Coding update:

Procedure codes: New codes take effect on 1-1-2021
- Adding: 0620T, 0621T, 0622T, 0623T, 0624T, 0625T, 0626T, 0627T, 0628T, 0629T, 0630T, 0631T, 0632T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0639T, 30468, 57465, 92229
- Removing: 0111T, 0126T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0396T, 0400T, 0401T, 0405T
Outpatient HCPCS (Codes)
- Adding: C1825, C9771, C9772, C9773, C9774, C9775

Internal Medical Policy Committee 3-17-2021 Coding Update:

Procedure codes:
- Adding 0243U, 0247U, K1016, K1017, K1018 and K1019;
- Removed K1010, K1011 and K1012 effective April 1, 2021

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Policy ID: Z-67-067

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: December 16, 2020

Revision Effective Date: January 01, 2021

Last Reviewed: January 19, 2021

Archived Date: March 31, 2021

Description

Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.

This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.

Criteria

Services meeting ANY of the following criteria are considered experimental/investigational:

The intervention does not have Food and Drug Administration (FDA) approval to be marketed for the specific relevant indication(s); or
Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
The intervention does not improve health outcomes; or
The intervention is not proven to be applicable outside the research setting.

Procedure Codes

0014M	0015M	0017M	0100T	0174T	0175T	0198T
0200T	0201T	0202T	0207T	0219T	0220T	0221T
0222T	0263T	0264T	0265T	0266T	0267T	0268T
0269T	0270T	0271T	0272T	0273T	0278T	0329T
0330T	0333T	0335T	0338T	0339T	0342T	0356T
0358T	0378T	0379T	0408T	0409T	0410T	0411T
0412T	0413T	0414T	0415T	0416T	0417T	0418T
0421T	0422T	0423T	0437T	0439T	0440T	0441T
0442T	0443T	0444T	0445T	0451T	0452T	0453T
0454T	0455T	0456T	0457T	0458T	0459T	0460T
0461T	0462T	0463T	0465T	0469T	0470T	0471T
0472T	0473T	0475T	0476T	0477T	0478T	0479T
0480T	0484T	0485T	0486T	0487T	0488T	0489T
0490T	0491T	0492T	0493T	0497T	0498T	0499T
0505T	0506T	0507T	0508T	0512T	0513T	0515T
0516T	0517T	0518T	0519T	0520T	0521T	0522T
0523T	0525T	0526T	0527T	0528T	0529T	0530T
0531T	0532T	0533T	0534T	0535T	0536T	0541T
0542T	0543T	0544T	0545T	0546T	0547T	0548T
0549T	0550T	0551T	0552T	0553T	0554T	0555T
0556T	0557T	0558T	0559T	0560T	0561T	0562T
0563T	0564T	0565T	0566T	0567T	0568T	0569T
0570T	0571T	0572T	0573T	0574T	0575T	0576T
0577T	0578T	0579T	0580T	0581T	0582T	0583T
0594T	0596T	0597T	0598T	0599T	0600T	0601T
0602T	0603T	0604T	0605T	0606T	0607T	0608T
0609T	0610T	0611T	0612T	0613T	0615T	0616T
0617T	0618T	0619T	0620T	0621T	0622T	0623T
0624T	0625T	0626T	0627T	0628T	0629T	0630T
0631T	0632T	0633T	0634T	0635T	0636T	0637T
0638T	0639T	0174U	0176U	0178U	30468	32994
33440	57465	64454	64625	90587	90689	91022
92145	92229	93895	96931	96932	96933	96934
96935	96936	A4563	K1001	K1006	K1009	K1010
K1011	K1012	L2006	L8608	L8701	L8702	Q0035
S9025

Outpatient HCPCS (C Codes)

C1734	C1748	C1824	C1825	C1839	C2596	C9250
C9758	C9759	C9760	C9762	C9763	C9764	C9765
C9766	C9767	C9771	C9772	C9773	C9774	C9775

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 new code update

Internal Medical Policy Committee 7-22-2020 Coding update for July HCPCS

Procedure Codes:
- Removed: 0124U; 0125U; 0126U; 0127U; 0128U
- Added: 0174U; 0176U; 0178U; 0596T; 0597T; 0598T; 0599T; 0600T; 0601T; 0602T; 0603T; 0604T; 0605T; 0606T; 0607T; 0608T; 0609T; 0610T; 0611T; 0612T; 0613T; 0615T; 0616T; 0617T; 0618T; 0619T.
Outpatient HCPCS (Codes)
- Added: C1748; C9759; C9760; C9762; C9763; C9764; C9765; C9766; C9767

Internal Medical Policy Committee 9-21-2020 Coding update:

Procedure codes:
- Adding: 0015M; K1006; K1009; K1010; K1011; and K1012

Internal Medical Policy Committee 11-19-20 Coding update:

Procedure codes:
- Removed 31647; 31648; 31649; 31651; 0424T; 0425T; 0426T; 0427T; 0428T; 0429T; 0430T; 0431T; 0432T; 0433T; 0434T; 0435T; 0436T and C1982

Internal Medical Policy Committee 11-19-21 Coding update:

Procedure codes: New codes take effect on 1-1-2021
- Adding: 0620T, 0621T, 0622T, 0623T, 0624T, 0625T, 0626T, 0627T, 0628T, 0629T, 0630T, 0631T, 0632T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0639T, 30468, 57465, 92229
- Removing: 0111T, 0126T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0396T, 0400T, 0401T, 0405T
Outpatient HCPCS (Codes)
- Adding: C1825, C9771, C9772, C9773, C9774, C9775

Links

References (PDF)

Disclaimer

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